Tubercular cerebellitis, identified through an expansive process: A case report

Abstract

Central nervous system (CNS) tuberculosis is a postprimary form of tuberculosis with high mortality and morbidity rates, even with early diagnosis and treatment. Focal tuberculous cerebritis is extremely rare, typically occurring in patients without AIDS, and often associated with tuberculous meningitis. In endemic regions, it should be a primary consideration when encountering cerebral anomalies suggestive of granulomatous conditions. Its meningeal pseudo-tumor form poses a significant diagnostic challenge. We present the case of a 26-year-old man who arrived at the emergency room with cerebellar and pyramidal syndrome. Cerebral magnetic resonance imaging (MRI) revealed an expansive lesion in the right hemicerebellum with glove-finger edema and leptomeningeal thickening. Given the MRI findings and associated lung involvement, the diagnosis of tuberculosis was strongly suggested in our epidemiological context. Due to contraindications for lumbar puncture, high surgical risk, and strong clinical and radiological suspicion, antituberculous treatment was initiated in collaboration with neurologists and infectious disease specialists. The clinical and radiologic manifestations of CNS tuberculosis can mimic other infectious and noninfectious neurological conditions, as seen in our patient. Thus, familiarity with the imaging presentations of CNS tuberculosis among infectious disease specialists and radiologists is crucial for prompt and accurate diagnosis.

Keywords: CNS tuberculosis; Conventional and multimodal MRI; Granulomatosis.

Fig. 1

(A-D) Fluid-attenuated inversion recovery axial image and coronal T2-weighted showing hyperintense signal intensity involving right cerebellar hemisphere with mass effect (A, B) ( arrow); Axial T2 and Postcontrast fat-suppressed T1-weighted axial image showing nodular leptomeningeal thickening, hypointense on T2-weighted (C) White star taking nodular and heterogeneous contrast (D) Blue star.

Fig. 2

Axial fluid-attenuated inversion recovery image showing hydrocephalus and periventricular ooze.

Fig. 3

(A, B) MR spectroscopy shows elevated choline peak (arrow) with increased choline to NAA ratio, and significant increase in lipid (Star) with inverted high lactate.

Fig. 4

(A, B) CT axial slice in parenchymal window showing some pulmonary nodules and micromodules in the lung parenchyma(star), as well as mediastinal lymphadenopathy with necrotic center (arrow).

Fig. 5

CT axial slice through the abdominal region showing a calcified lymph node formation, likely a sequela of tuberculous lymphadenitis (arrow).